Department of the Treasury Internal Revenue Service
Public Charity Status and Public Support
Complete if the organization is a section 501(c)(3) organization or a section
4947(a)(1) nonexempt charitable trust.
Attach to Form 990 or Form 990-EZ. See separate instructions. Information about Schedule A (Form 990 or 990-EZ) and its instructions is at www.irs.gov/form990.
OMB No. 1545-0047
2013
Open to Public Inspection
Name of the organization
Lehigh Valley Hospital - Muhlenberg
Employer identification number
23-2367707
Part I
Reason for Public Charity Status
(All organizations must complete this part.) See instructions.
The organization is not a private foundation because it is: (For lines 1 through 11, check only one box.)
1
2
3
4
5
section 170(b)(1)(A)(iv). (Complete Part II.)
6
7
8
9
receipts from activities related to its exempt functions—subject to certain exceptions, and (2) no more than 331/3% of
its support from gross investment income and unrelated business taxable income (less section 511 tax) from businesses
acquired by the organization after June 30, 1975. See section 509(a)(2). (Complete Part III.)
10
11
e
By checking this box, I certify that the organization is not controlled directly or indirectly by one or more disqualified persons other than foundation managers and other than one or more publicly supported organizations described in section 509(a)(1) or section 509(a)(2).
f
If the organization received a written determination from the IRS that it is a Type I, Type II, or Type III supporting organization, check this box
..................................................
g
Since August 17, 2006, has the organization accepted any gift or contribution from any of the following persons?
(i) A person who directly or indirectly controls, either alone or together with persons described in (ii)
Yes
No
and (iii) below, the governing body of the supported organization?
................
11g(i)
(ii)
A family member of a person described in (i) above?
......................
11g(ii)
(iii)
A 35% controlled entity of a person described in (i) or (ii) above?
................
11g(iii)
h
Provide the following information about the supported organization(s).
(i) Name of supported organization
(ii) EIN
(iii) Type of organization (described on lines 1- 9 above or IRC section (see instructions))
(iv) Is the organization in col. (i) listed in your governing document?
(v) Did you notify the organization in col. (i) of your support?
(vi) Is the organization in col. (i) organized in the U.S.?
(vii) Amount of monetary support
Yes
No
Yes
No
Yes
No
Total
For Paperwork Reduction Act Notice, see the Instructions for Form 990 or 990EZ.
Cat. No. 11285F
Schedule A (Form 990 or 990-EZ) 2013
Schedule A (Form 990 or 990-EZ) 2013
Page 2
Part II
Support Schedule for Organizations Described in Sections 170(b)(1)(A)(iv) and 170(b)(1)(A)(vi) (Complete only if you checked the box on line 5, 7, or 8 of Part I or if the
organization failed to qualify under Part III. If the organization fails to
qualify under the tests listed below, please complete Part III.)
Section A. Public Support
Calendar year (or fiscal year beginning in)
(a) 2009
(b) 2010
(c) 2011
(d) 2012
(e) 2013
(f) Total
1
Gifts, grants, contributions, and membership fees received. (Do not include any "unusual grants.") ....
2
Tax revenues levied for the organization's benefit and either paid to or expended on its behalf.......
3
The value of services or facilities furnished by a governmental unit to the organization without charge..
4
Total. Add lines 1 through 3
5
The portion of total contributions by each person (other than a governmental unit or publicly supported organization) included
on line 1 that exceeds 2% of the amount shown on line 11, column (f)..
6
Public support. Subtract line 5 from line 4.
Section B. Total Support
Calendar year
(or fiscal year beginning in)
(a) 2009
(b) 2010
(c) 2011
(d) 2012
(e) 2013
(f) Total
7
Amounts from line 4..
8
Gross income from interest, dividends, payments received on securities loans, rents, royalties and income from similar sources...
9
Net income from unrelated business activities, whether or not the business is regularly carried on..
10
Other income. Do not include gain or loss from the sale of capital assets (Explain in Part IV.)..
11
Total support (Add lines 7 through 10).
12
Gross receipts from related activities, etc. (see instructions)
..................
12
13
First five years.
If the Form 990 is for the organization's first, second, third, fourth, or fifth tax year as a 501(c)(3) organization,
check this box and stop here.................................................
Section C. Computation of Public Support Percentage
14
Public support percentage for 2013 (line 6, column (f) divided by line 11, column (f))
.........
14
15
Public support percentage for 2012 Schedule A, Part II, line 14
...............
15
16a
33 1/3% support test—2013.
If the organization did not check the box on line 13, and line 14 is 33 1/3% or more, check this box
and stop here. The organization qualifies as a publicly supported organization
.......................
b
33 1/3% support test—2012.
If the organization did not check a box on line 13 or 16a, and line 15 is 33 1/3% or more, check this
box and stop here. The organization qualifies as a publicly supported organization
.....................
17a
10%-facts-and-circumstances test—2013.
If the organization did not check a box on line 13, 16a, or 16b, and line 14
is 10% or more, and if the organization meets the "facts-and-circumstances" test, check this box and stop here. Explain
in Part IV how the organization meets the "facts-and-circumstances" test. The organization qualifies as a publicly supported
organization
.....................................................
b
10%-facts-and-circumstances test—2012.
If the organization did not check a box on line 13, 16a, 16b, or 17a, and line
15 is 10% or more, and if the organization meets the "facts-and-circumstances" test, check this box and stop here.
Explain in Part IV how the organization meets the "facts-and-circumstances" test. The organization qualifies as a publicly supported organization
................................................
18
Private foundation.
If the organization did not check a box on line 13, 16a, 16b, 17a, or 17b, check this box and see
instructions
.....................................................
Schedule A (Form 990 or 990-EZ) 2013
Schedule A (Form 990 or 990-EZ) 2013
Page 3
Part III
Support Schedule for Organizations Described in Section 509(a)(2) (Complete only if you checked the box on line 9 of Part I or if the organization
failed to qualify under Part II. If the organization fails to qualify under
the tests listed below, please complete Part II.)
Section A. Public Support
Calendar year (or fiscal year beginning in)
(a) 2009
(b) 2010
(c) 2011
(d) 2012
(e) 2013
(f) Total
1
Gifts, grants, contributions, and membership fees received. (Do not include any "unusual grants.") .
2
Gross receipts from admissions, merchandise sold or services performed, or facilities furnished in any activity that is related to the organization's tax-exempt purpose......
3
Gross receipts from activities that are not an unrelated trade or business under section 513..
4
Tax revenues levied for the organization's benefit and either paid to or expended on its behalf...
5
The value of services or facilities furnished by a governmental unit to the organization without charge..
6
Total. Add lines 1 through 5.
7a
Amounts included on lines 1, 2, and 3 received from disqualified persons...
b
Amounts included on lines 2 and 3 received from other than disqualified persons that exceed the greater of $5,000 or 1% of the amount on line 13 for the year.
c
Add lines 7a and 7b..
8
Public support (Subtract line 7c from line 6.)
Section B. Total Support
Calendar year (or fiscal year beginning in)
(a) 2009
(b) 2010
(c) 2011
(d) 2012
(e) 2013
(f) Total
9
Amounts from line 6...
10a
Gross income from interest, dividends, payments received on securities loans, rents, royalties and income from similar sources..
b
Unrelated business taxable income (less section 511 taxes) from businesses acquired after June 30, 1975.
c
Add lines 10a and 10b.
11
Net income from unrelated business activities not included in line 10b, whether or not the business is regularly carried on.
12
Other income. Do not include gain or loss from the sale of capital assets (Explain in Part IV.)
..
13
Total support. (Add lines 9, 10c, 11, and 12.)..
14
First five years.
If the Form 990 is for the organization's first, second, third, fourth, or fifth tax year as a 501(c)(3) organization,
check this box and stop here.............................................
Section C. Computation of Public Support Percentage
15
Public support percentage for 2013 (line 8, column (f) divided by line 13, column (f))
.........
15
16
Public support percentage from 2012 Schedule A, Part III, line 15
...............
16
Section D. Computation of Investment Income Percentage
17
Investment income percentage for 2013 (line 10c, column (f) divided by line 13, column (f))
......
17
18
Investment income percentage from 2012 Schedule A, Part III, line 17
.............
18
19a
33 1/3% support tests—2013.
If the organization did not check the box on line 14, and line 15 is more than 33 1/3%, and line 17 is not more than 33 1/3%, check this box and stop here. The organization qualifies as a publicly supported organization
........
b
33 1/3% support tests—2012.
If the organization did not check a box on line 14 or line 19a, and line 16 is more than 33 1/3% and line 18 is not more than 33 1/3%, check this box and stop here. The organization qualifies as a publicly supported organization
.....
20
Private foundation.
If the organization did not check a box on line 14, 19a, or 19b, check this box and see instructions
.....
Schedule A (Form 990 or 990-EZ) 2013
Schedule A (Form 990 or 990-EZ) 2013
Page 4
Part IV
Supplemental Information.
Provide the explanations required by Part II, line 10; Part II, line 17a or 17b; and Part III, line 12. Also complete this part for any additional information. (See instructions).
Facts And Circumstances Test
Explanation
Schedule A (Form 990 or 990-EZ) 2013
Additional Data
Software ID:
Software Version:
-
TIN:
SCHEDULE O (Form 990 or 990-EZ)
Department of the Treasury Internal Revenue Service
Supplemental Information to Form 990 or 990-EZ
Complete to provide information for responses to specific questions on
Form 990 or to provide any additional information.
Attach to Form 990 or 990-EZ.
Information about Schedule O (Form 990 or 990-EZ) and its instructions is at
www.irs.gov/form990.
OMB No. 1545-0047
2013
Open to Public Inspection
Name of the organization
Lehigh Valley Hospital - Muhlenberg
Employer identification number
23-2367707
Return Reference
Explanation
Form 990, Part VI, Section B, line 11
The process to review the 990's includes: Draft 1 of the returns is reviewed in detail with a focus on accuracy, completeness, and perspective by the LVHN Controller and the LVHN Corporate Legal Counsel. Draft 2 of the returns is reviewed by the Chief Financial Officer. All Compensation disclosures are reviewed by the Director - Compensation - Human Resources. Draft 3 of the returns is reviewed together with the President & CEO, the Chief Financial Officer, the Controller and the Director-Tax. Final Returns are reviewed with LVHN Executive Committee of the Board of Trustees prior to their filing.
Form 990, Part VI, Section B, line 12c
Pursuant to the LVHN policy titled "Avoidance of Conflict of Interest/Commitment", the VP of Internal Audit and Compliance Services (Chief Compliance Officer or CCO) issues reminders to Board Members and members of the Senior Management Council to submit updated conflict of interest questionnaires; and (2) notifies members of the Senior Management Council (SMC) to identify and request completed conflict of interest questionnaires from individuals who report to them or have responsibilities that affect their operations and who have potential conflicts of interest and to provide her with the identity of those individuals. Compliance Services tracks completion of the updated questionnaires and sends reminders to those who have not yet submitted them, as the deadline for completion approaches. The CCO follows up with trustees and members of the SMC who have not submitted a completed questionnaire by the deadline in an effort to ensure that questionnaires are on file for all to whom the policy applies. All physicians on LVHN's medical staff are also required to complete a conflict of interest questionnaire annually. Medical Staff Services monitors this process to ensure that all physicians comply. Potential conflicts are managed by the LVHN Conflict of Interest Committee and by the Board of Trustees, if necessary, depending on whose interest(s) pose the conflict and the nature of the conflict.
Form 990, Part VI, Section B, line 15
The Executive Compensation Committee ("Committee") of the Board of Trustees of Lehigh Valley Health Network ("LVHN") is authorized to perform its functions for and on behalf of LVHN. The purpose of the Committee is to discharge the obligations of the Board of Trustees relating to the oversight and approval of Senior Management Council compensation and their ongoing professional development in accordance with applicable rules and regulations. Committee Organization: 1. The Committee shall be composed of at least four (4) members of the Board of Trustees, one of whom shall serve as Chair of the Committee. The Committee shall be composed entirely of Trustees who are entirely disinterested members of the Board. The Trustees will have no material relationship to LVHN and/or its Senior Management Council members that may limit their disinterestedness in this role, including that the Trustees (i) must not have any personal interest in the compensation arrangement, (ii) must not be related to or under the control of the person whose compensation is being evaluated, and (iii) must have no material business relationship with LVHN. If a proposed member of the Committee has identified a potential conflict of interest, the issue shall be reviewed by the disinterested members of the Audit and Compliance Committee which shall report its findings to the Chair of the Executive Compensation Committee. Based on that review, the Chair and the Committee, absent the member with a potential conflict, will make the final determination as to the disinterestedness of the Trustee and the appropriateness of service. From time to time, there may be specific situations which pose a potential conflict of interest. In such instances, the Committee will make the appropriate determination. The Committee may also establish such other procedures as it may deem appropriate with respect to the disinterested status of its members, subject to Board approval. 2. The members and the Chair of the Committee shall be appointed each year by the Board of Trustees in accordance with its policies, and shall serve at the pleasure of the Board of Trustees for such term or terms as the Board of Trustees may determine. The Committee shall conduct its activities in conformity with the requirements of the LVHN By-Laws and the requirements of the Internal Revenue Code of 1986, and Regulations promulgated thereunder, together with any further obligations or requirements as directed by the Board. 3. Each Committee Member shall have the following qualifications: Ability to critically review performance and market practice data and apply relevant information fairly, while properly balancing the competing needs of LVHN's stakeholders. Ability to consider the objectives of linking compensation to performance and retaining high-performing personnel, all in the best interests of LVHN and in accordance with its charitable mission. An understanding of the market place regarding the attraction and retention of Senior Management Council employees and other key personnel. Functions, Duties and Authorities: The Committee on an annual basis shall: Assess the performance of the President/Chief Executive Officer, determine the President/Chief Executive Officer's compensation, discuss the appraisal with the President/Chief Executive Officer and report its determination generally to the full Board. Review the performance of all other members of the Senior Management Council and approve their compensation considering the recommendations of the President/Chief Executive Officer, and report its determinations generally to the full Board. Review the performance of disqualified persons and other individuals in key leadership positions as determined by the Committee. Review the succession plan and professional and career development of senior management in the organization. Review the compensation plan for selected physicians, including LVPG. Assure that any applicable Senior Management Committee Member's compensation arrangement (new hire, transfer, promotion or demotion) is reviewed and approved in advance by the Committee in accordance with all applicable rules and regulations, including Section 4958 of the Internal Revenue Code or its successor. In particular, the Committee intends that its determinations qualify for the "Rebuttable Presumption of Reasonableness" and thus it will ensure that: A compensation arrangement is approved in advance only by Committee members who do not have a conflict of interest with respect to the arrangement, It relies upon appropriate, independent comparability data prior to making its determination, and The basis for the determination is adequately documented concurrent with the Committee's approval. Adequate documentation requires (i) the terms of compensation, (ii) date of approval, (iii) members present, (iv) the source of comparability information and the data, (v) rationale for compensation levels that fall at the upper end of the comparability data, and (vi) any actions taken with respect to conflicts of interest of any member of the Committee. The documentation must be prepared by the later of the next meeting of the Committee or 60 days after final action and approved within a reasonable time thereafter. The Committee, with respect to the administration of the Retirement, Severance and Health & Welfare Plans shall: Appoint the Plan Administrator Delegate the day-to-day functions of plan administration to the Plan Administrator. Specifically these delegated duties shall include: convene a pension administration committee compliance with ERISA and IRS documentation and reporting requirements oversight and management of the benefit claims appeal process preparation and distribution of disclosures to Plan participants provide an annual report which include plan administration activities of the retirement, severance and health and welfare plans. Make recommendations to the LVHN Board regarding Retirement Plan design. Specific responsibilities shall include: reviewing and making recommendations on the benefit structure, the Plan Document or Trust Agreement; review and recommend additions or deletions of organizational divisions covered by the Plan. The Committee shall also: Consider and make recommendations to the Board regarding the compensation philosophy for the Senior Management Council. Annually evaluate the performance and function of the Committee, including a review of its compliance with this Charter. Direct the establishment of a process that ensures compensation information is fully and fairly disclosed on the Form 990. Discharge such additional duties and responsibilities as the Board of Trustees may from time to time assign to it.
Form 990, Part VI, Section C, line 18
Anothers Website - Guidestar. Upon request - hard copies with senior management and marketing.
Form 990, Part VI, Section C, line 19
The Organization makes its financial statements available to the public through its Annual Report to the community. The Annual Report is distributed to all attendees at the Organizations annual public meeting. In addition, it is distributed via mail to members of the community. The Organizations governing documents and conflict of interest policy are not made available to the public.
Form 990, Part IX, line 11g
Lab Test Fees: Program service expenses 13,617,399. Management and general expenses 0. Fundraising expenses 0. Total expenses 13,617,399. Physician Fees: Program service expenses 7,928,285. Management and general expenses 0. Fundraising expenses 0. Total expenses 7,928,285. Other Fees : Program service expenses 3,834,345. Management and general expenses 1,144,900. Fundraising expenses 0. Total expenses 4,979,245.
Form 990, Part XI, line 9:
Change in net realized gains/losses - restricted funds 400,256.
Form 990, Part XI, Line 2c
The Audit Committee of the Board of Trustees assumes responsibility for oversight of the audit and selection of an independent auditor.
Form 990, Part VI, Line 16b
Although the organization does not have a written policy with respect to evaluation of participation in joint venture arrangements, no joint venture is entered into without having had the transactional documents reviewed and evaluated by outside counsel and, if necessary, consultants and accountants to assure that the arrangement does not, in any manner, compromise the organization's exempt status and mission.
Form 990, Part VII, Line 1a
Hours worked by these individuals reflect the combined hours spent as a Board Officer and an Employee of the organization. All compensation, benefits, etc. reported are for work as a member of senior management of the organization. The remainder of the officers, trustees, listed above are volunteers and receive no compensation.
For Paperwork Reduction Act Notice, see the Instructions for Form 990 or 990-EZ.